Healthcare Provider Details

I. General information

NPI: 1861443202
Provider Name (Legal Business Name): WALLACE BROADBENT D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/12/2006
Last Update Date: 02/10/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1535 GULL RD MSB 015
KALAMAZOO MI
49048-1650
US

IV. Provider business mailing address

1535 GULL RD MSB 015
KALAMAZOO MI
49048-1650
US

V. Phone/Fax

Practice location:
  • Phone: 269-226-6933
  • Fax: 269-226-6949
Mailing address:
  • Phone: 269-226-6933
  • Fax: 269-226-6949

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number5101011784
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number5101011784
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: